Provider Demographics
NPI:1881302867
Name:BULLOCK, HEATHER PATRICIA (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:PATRICIA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2017 W I 35 FRONTAGE RD STE 130
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8554
Mailing Address - Country:US
Mailing Address - Phone:405-757-3630
Mailing Address - Fax:405-757-3631
Practice Address - Street 1:2017 W I 35 FRONTAGE RD STE 130
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8554
Practice Address - Country:US
Practice Address - Phone:405-757-3630
Practice Address - Fax:405-757-3631
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant